Transcript Detection of Mental Health Problems in Primary Care

Health service utilization by
patients with common mental
disorder identified by the Self
Reporting Questionnaire in a
primary care setting in Zomba,
Malawi
Michael Udedi,
Leslie Swartz, Robert Stewart & Felix
Kauye
Background
• In Malawi, as in other developing countries in Sub-Saharan
Africa, access to services for people with mental health
problems is poor.
• Non specialized health care workers provide mental health
services in the primary care settings in Malawi and given the
workload at primary health care (PHC) setting level, little time
is available to screen for mental disorders hence may go
unrecognized.
• There is a possibility that a significant proportion of patients
attending to primary care in Malawi may have common
mental disorders (CMDs).
• Consequently, the possibility of misdiagnosis may lead to
higher service utilization by people with common mental
health problems.
Aim of the study
• The aim of the study was to evaluate health
services utilization patterns of patients with
CMDs in primary care clinics.
Methodology for study
• A cross-sectional quantitative survey was done among
patients attending outpatient department at Matawale and
Domasi Health Centre in Zomba in Sept & Oct 2012.
• The study included all consecutive patients aged 18 years and
older who attended the primary health care clinics for any
reason.
• Face-to-face
interviews
with
the
Self-Reporting
Questionnaires (SRQ-20), PHC Encounter Forms and Health
Service Utilization Forms were conducted in a sample of 323
primary health care attendees.
• Ethical approval was obtained from both the Health Research
Ethics Committee at Stellenbosch University, South Africa and
the College of Medicine Research and Ethics Committee,
University of Malawi, Malawi
Results (1)
• The sociodemographic profiles of the
participants revealed that majority of them
were: in the age group 18-31(41.8%); females
(74%); Christians (67%); married (65%); and
unemployed (55%).
• The prevalence of probable CMD was 20.1%.
• People with CMD had a higher average
number of health facility visits in the previous
three months compared to those without
probable CMD thus 1.6 vs. 1.19 (p-value 0.02).
Results (2)
• The total average number of both health facility and
traditional healer visits were 1.68 vs. 1.24 (p-value
0.019), for people with probable CMD having a
higher average compared to those without a
probable CMD.
• It was found that people who have visited the health
care facility repeatedly in the past 3 months were
likely to be suffering from CMD. The odds of
probable CMD increased with each visit to health
facility by 1.27 (p-value=0.024).
• Almost all those who had probable CMD had no
treatment prescribed for CMD by PHC clinicians.
Table 1. Pattern of use of health service among
participants with probable common mental disorder
and non-probable common mental disorder
Average
number of
visits in past
three months
Probable CMD Non-probable P value
CMD
Average number
of visits to health
facility
Average number
of visits to
traditional healer
Total average
number of visits
to health facility
and traditional
healer
1.6
1.19
0.02
0.05
0.08
0.565
1.68
1.24
0.019
Table 2. Model on number of visit to health
facility or traditional healer associated with
probable common mental disorder
Variable
Step 1a
Probable CMD
B
Wald
OR [Exp(B)] Sig.
Number of times for Health Facility
0.239 5.077
1. 270
0.024
0.130 0.085
1. 138
0. 770
-1.718 65.857 0.179
<0.001
visit
Number of times for Traditional
Healers visit
Constant
Discussion
• The prevalence of probable common mental disorders in
this setting is similar to other findings from developing
countries where the prevalence rate of mental common
mental disorder ranges from 20 to 30% (Patel & Kleinman,
2003).
• The study found that people with probable common
mental disorder had a higher average number of health
facility visits in the previous three months compared to
those without probable common mental disorder.
• A number of studies have established a relationship
between frequent visit to primary health care to common
mental disorders (Jacobi, Klose, & Wittchen, 2004; Kramer
& Garralda, 2000; Tansella, 2005).
Discussion
• As in other studies, the study found a very low
detection rate of mental disorder by PHC clinicians
(Avasthi, et al., 2008; Badamgarav, et al., 2003; LichtStrunk, et al., 2009; Ndetei, et al., 2009).
• This could be attributed to both patient and clinician
factors –patients may not mention mental disorder
symptoms to their clinician or clinicians may not ask
about these symptoms, possibly through lack of
knowledge or because of attitudinal issues, or
because of high workloads.
Implications for research
• Further research to determine the nature and
prevalence of CMDs in the community and in
attendees of traditional healers, given the findings of
the present study.
• Future research to investigate the awareness of
mental health, the help seeking behaviour of
patients with mental health problems in the
community and the use of healthcare service in the
community, in order to come up with evidence based
mental health strategies.
Implications for research
• Given the likely influence of physical symptoms on
the misdiagnoses of CMD, a qualitative study is
imperative to explore whether non specific
diagnoses may constitute proxies for expressing
common mental disorder, or may be indicative of
somatization.
– As part of that study, diagnostic practices of
clinicians could also be explored, examining
whether clinicians use these categories to avoid
diagnosing stigmatised common mental disorders.
Implications for policy and
practice
• Improving patient outcomes and reducing re-attendances can
be achieved through improved recognition of psychological
symptoms.
• There is a need for primary health care workers to be
refreshed periodically on identifying and treating common
mental health disorders through continuing professional
development programme (CPD).
• Intervention on patient disclosure could also be effective in
assisting to improve clinician recognition hence there is need
to direct efforts towards creating awareness about mental
health and encourage patient disclosure of psychological or
mental health issues.
Conclusion
• This study has revealed the magnitude of
common mental disorder that is prevalent in the
primary health care centres that goes
unrecognized and untreated.
• The high utilization of health services suggests
that there may be a large treatment gap in terms
of mental health care in the primary care setting.
• The study also showed that the screening
questionnaire for mental disorders could identify
primary care patients who are at risk for common
mental disorder and higher utilization.
Acknowledgement
•
•
•
•
Prof. Leslie Swartz
Dr. Felix Kauye
Dr. Rob Stewart
The Africa Focus on Intervention Research for
Mental Health (AFFIRM)
• The Scotland Malawi Mental Health Education
Project (SMMHEP)
• Zomba Mental Hospital
• All the study participants